Stanford Health Policy is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford School of Medicine
FSI scholars produce research aimed at creating a safer world and examing the consequences of security policies on institutions and society. They look at longstanding issues including nuclear nonproliferation and the conflicts between countries like North and South Korea. But their research also examines new and emerging areas that transcend traditional borders – the drug war in Mexico and expanding terrorism networks. FSI researchers look at the changing methods of warfare with a focus on biosecurity and nuclear risk. They tackle cybersecurity with an eye toward privacy concerns and explore the implications of new actors like hackers.
Along with the changing face of conflict, terrorism and crime, FSI researchers study food security. They tackle the global problems of hunger, poverty and environmental degradation by generating knowledge and policy-relevant solutions.
A new four-paper series in The Lancet exposes the far-reaching effects of modern warfare on women’s and children’s health.
In March 2020, when many U.S. states and localities issued their first emergency orders to address Covid-19, there was widespread acceptance of the government’s legal authority to respond quickly and aggressively to this unprecedented crisis. Today, that acceptance is fraying. As initial orders expire and states move to extend or modify them, legal challenges have sprouted. The next phase of the pandemic response will see restrictions dialed up and down as threat levels change. As public and political resistance grows, further legal challenges are inevitable.
Urgent responses to the Covid-19 pandemic have halted movement and work and dramatically changed daily routines for much of the world’s population. In the United States, many states and localities have ordered or urged residents to stay home when able and to practice physical distancing when not. Meanwhile, unemployment is surging, schools are closed, and businesses have been shuttered. Resistance to drastic disease-control measures is already evident. Rising infection rates and mortality, coupled with scientific uncertainty about Covid-19, should keep resentment at bay — for a while. But the status quo isn’t sustainable for months on end; public unrest will eventually become too great.
Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership.
We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns).
A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition.
Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.)
Millions of Americans have experienced the coronavirus pandemic directly, as they or their loved ones suffered through infection. But for most of us, the experience is defined by weeks and months on end stuck at home. The shut-ins are testing the safety of our home environments. Stress and isolation combined with another feature of American life — easy access to firearms — could form a deadly brew. Last week we released results of a new study — the largest ever on the connection between suicide and handgun ownership — in The New England Journal of Medicine revealing that gun owners were nearly four times as likely to die by suicide than people without guns, even when controlling for gender, age, race and neighborhood.
Yet there has been no national-level, comprehensive review of the evidence for public health emergency preparedness and response (PHEPR) practices. Recognizing this deficiency, the Centers for Disease Control and Prevention (CDC) went to the National Academies of Sciences, Engineering and Medicine three years ago and asked them to convene a national panel of public health experts to review the evidence for emergency preparedness and response. The committee members included Stanford Health Policy Director Douglas K. Owens. The committee issued its findings July 14 with a report at a Zoom conference.
The toll from gun violence at schools has only escalated in the 20 years since the jolting, horrific massacre at Columbine High.
By December 2019, at least 245 primary and secondary schools in the United States had experienced a shooting, killing 146 people and injuring 310, according to The Washington Post.
At least 245 primary and secondary schools in the United States have experienced a shooting — killing 146 people and injuring 310 — since the country's first mass school shooting at Columbine High School in April 1999.
Now, new Stanford-led research sounds an alarm to what was once a silent reckoning: the mental health impact to tens of thousands of surviving students who were attending schools where gunshots rang out.
A study has found that local exposure to fatal school shootings increased antidepressant use among youths.
Specifically, the average rate of antidepressant use among youths under age 20 rose by 21 percent in the local communities where fatal school shootings occurred, according to the study. And the rate increase – based on comparisons two years before the incident and two years after – persisted even in the third year out.
“There are articles that suggest school shootings are the new norm – they’re happening so frequently that we’re getting desensitized to them – and that maybe for the people who survive, they just go back to normal life because this is just life in America. But what our study shows is that does not appear to be the case,” said Maya Rossin-Slater, a core faculty member at Stanford Health Policy and faculty fellow at the Stanford Institute for Economic Policy Research (SIEPR). “There are real consequences on an important marker of mental health.”
The study is detailed in a working paper published Monday by the National Bureau of Economic Research. It was co-authored by Rossin-Slater, an assistant professor of health policy in the Stanford School of Medicine; Molly Schnell, a former postdoctoral fellow at SIEPR now an assistant professor at Northwestern University; Hannes Schwandt, an assistant professor at Northwestern and former visiting fellow at SIEPR; Sam Trejo, a Stanford doctoral candidate in economics and education; and Lindsey Uniat, a former predoctoral research fellow at SIEPR now a PhD student at Yale University.
Their collaborative research – accelerated by their simultaneous stints at SIEPR – is the largest study to date on the effects of school shootings on youth mental health.
The study comes as the issue of gun safety continues to stoke political wrangling and public debate. And the researchers say their findings suggest policymakers should take a wide lens to their decision-making process.
“When we think about the cost of school shootings, they’re often quantified in terms of the cost to the individuals who die or are injured, and their families,” Rossin-Slater noted. “Those costs are unfathomable and undeniable. But the reality is that there are many more students exposed to school shootings who survive. And the broad implication is to think about the cost not just to the direct victims but to those who are indirectly affected.”
More than 240,000 students have been exposed to school shootings in America since the mass shooting in Columbine in April 1999, according to The Washington Post data used in the study. And the number of school shootings per year has been trending up since 2015.
Yet despite this “uniquely American phenomenon” – since 2009, over 50 times more school shootings have occurred in the U.S. than in Canada, Japan, Germany, Italy, France and the United Kingdom combined – little is known about the effects of such gun violence on the mental health of the nation’s youth, the study stated.
“We know that poor mental health in childhood can have negative consequences throughout life,” Schwandt said. “At the same time, children are known to show significant levels of resilience, so it really wasn’t clear what we would find as we started this project.”
The researchers examined 44 shootings at schools across the country between January 2008 and April 2013. They used a database that covered the near universe of prescriptions filled at U.S. retail pharmacies along with information on the address of the medical provider who prescribed each drug. They compared the antidepressant prescription rates of providers practicing in areas within a 5-mile radius of a school shooting to those practicing in areas 10-to-15 miles away, looking at two years prior and two to three years after the incident.
Of those 44 school shootings, 15 of them involved at least one death. The 44 shootings occurred in 10 states: Alabama, California, Connecticut, Florida, Nebraska, North Carolina, Ohio, South Carolina, Tennessee and Texas.
Researchers found a marked increase in the rate of antidepressant prescriptions for youths nearby, but only for the shootings that were fatal. They did not see a significant effect on prescriptions for youths exposed to non-fatal school shootings.
“The immediate impact on antidepressant use that we find, and its remarkable persistence over two, and even three years, certainly constitutes a stronger effect pattern than what we would have expected,” Schwandt said.
Meanwhile, adult antidepressant use did not appear to be significantly impacted by local exposure to school shootings.
The researchers also analyzed whether the concentration of child mental health providers in areas affected by fatal school shootings made a difference in the antidepressant rates, and they drilled a further comparison between the prevalence of those who can prescribe drugs, such as psychiatrists and other medical doctors, and those who cannot prescribe drugs, such as psychologists and licensed social workers.
Increases in antidepressant rates were the same across areas with both high and low concentrations of prescribing doctors, the researchers found. But in areas with higher concentrations of non-prescribing mental health providers, the increases in antidepressant use were significantly smaller – indicating perhaps a greater reliance on non-pharmacological treatments or therapy for shooting-related trauma.
The researchers also found no evidence that the rise in antidepressant usage stemmed from mental health conditions that were previously undiagnosed prior to the shootings.
In totality, the researchers say the results in the study clearly pointed to an adverse impact from a fatal shooting on the mental health of youths in the local community. Furthermore, the results capture only a portion of the mental health consequences: Non-drug related treatments could have been undertaken as well.
“Increased incidence of poor mental health is at least part of the story,” Schnell said.
Though their analysis included only 44 schools and 15 fatal school shootings, Rossin-Slater noted how the trend of school shootings is growing. She believes the mental health impact found on the local communities they studied “can be generalizable to other communities’ experiences.”
That’s all the more reason why policymakers should consider the overall negative effects of school shootings, and how further research will be needed to gauge other societal consequences, the researchers said.
“Think of it as layers of costs,” Rossin-Slater said. And when it comes to evaluating gun violence at schools, “we think our numbers say, ‘Hey, these are costly things, and it’s costlier than we previously thought.’”
Americans have witnessed repeated mass shootings. The carnage in Texas and Ohio last weekend claimed another 31 lives and has left the nation stunned and angry.
Many are demanding that members of Congress pass tougher gun-control laws; others blame mental health and violent video games for the rampant shootings.
Stanford Health Policy’s David Studdert — an expert on the public health epidemic of firearms violence — acknowledges that mass shootings are on the rise in the United States.
“It’s been a horrific weekend,” said Studdert, a professor of law at Stanford Law School and professor of medicine at Stanford School of Medicine. “Experts now generally agree that mass shootings are becoming more common — and that a common thread is disaffected young men who have access to high-caliber, high-capacity weapons.”
Both suspects in the Dayton and El Paso shootings fit this profile.
Studdert notes, however, that while mass shootings have become the public face of gun violence, they account for less than 1% of the 40,000 firearm deaths each year.
“So as a public health researcher, I do care about mass shootings and I am interested in understanding and their causes — but the focus of my ongoing research is the other 99 percent.”
Largest investment in firearms research in two decades
It’s that focus the Studdert will be pursuing in a recently-awarded $668,000 grant from the National Collaboration on Gun Violence Research. The private collaborative’s mission is to fund nonpartisan, scientific research that offers the public and policymakers a factual basis for developing fair and effective gun policies.
Studdert, Yifan Zhang, a statistician with Stanford Health Policy, and Stanford political scientist Jonathan Rodden are working with colleagues at UC Davis, Northeastern University and Erasmus University Rotterdam on the Study of Handgun Ownership and Transfer, or LongSHOT.
The team is following several million Californians over a 12-year period to better understand the causal relationship between firearm ownership and mortality. They launched in 2016 with the initial goal of assessing the risks and benefits of ownership for firearm owners.
“The implications of firearm ownership for owners is important because they usually are the ones making the decision to purchase and own,” Studdert said. “But we knew from the beginning that this was only part of the picture. The presence of a firearm in the home may also have health implications for the owners’ family members.”
In the new study, the researchers will identify the cohort of adults in California who live with firearm owners but are not themselves gun owners, and then compare their risks of mortality to a group who neither own weapons, nor live with others who do.
Surprisingly little is known about the “secondhand” effects of having guns in the home.
“Existing studies don’t differentiate between owners and non-owners within households, and that is something we have the ability to look at,” Studdert said. “And a very large proportion of non-gun-owners who are living in homes with guns are women — so this is a group that has really been understudied.”
There is already substantial evidence that a gun in the home is associated with increased risks of suicide. But it is not clear how particular subgroups, such as women who don’t own guns, are affected.
“Because our cohort is so large,” Studdert said, “we will also be able to explore whether gun ownership confers certain benefits, as gun-rights advocates often claim, such as enhanced safety in dangerous neighborhoods.”
Studdert said a better accounting of the risks and benefits that firearm ownership poses for non-owners could help inform decisions regarding gun ownership and storage, as well as policies aimed at improving gun safety.
The politics of federal funding for firearms research
The National Collaboration on Gun Violence Research is funded through private philanthropic donations. It was seeded with a $20 million gift from Arnold Ventures and intends to raise another $30 million in private funding for firearms research.
“It’s the biggest investment in firearms research since the late 1990s,” Studdert said.
Research on the impact and causes of firearm violence was dealt a huge blow in 1996 when the so-called Dickey Amendment was passed by Congress. The law has been interpreted as prohibiting the National Institutes of Health and the Centers for Disease Control and Prevention from conducting firearms research.
Studdert said that the growth of research funding from philanthropies like the Arnold Foundation and Joyce Foundation is a welcome development, but that it will take a large and sustained investment to move the science of firearm violence forward.
“The core funder of large-scale research essentially vacated the space for 20 years,” he said. “It’s going to take some time to recover. Developing a generation of researchers with expertise will take give to 10 years. But it has to be done — the size of the social problem demands it.”
Opioids overdoses now kill more Americans than car accidents or guns, with more than 350,000 Americans having succumbed to the painkillers since 2000.
“The opioid misuse and overdose crisis touches everyone in the United States,” Health and Human Services Secretary Alex Azar said in this recent report. “The effects of the opioid crisis are cumulative and costly for our society — an estimated $504 billion a year in 2015 — placing burdens on families, workplaces, the health care system, states, and communities.”
Now, new research led by Stanford shows that not only have opioid-related deaths jumped fourfold in the last 20 years, but that those most affected by the epidemic, and where they live, has also shifted dramatically. In fact, the District of Columbia has had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013.
“Although opioid-related mortality has been stereotyped as a rural, low-income phenomenon concentrated among Appalachian or midwestern states, it has spread rapidly, particularly among the eastern states,” writes Mathew V. Kiang, ScD, a research fellow at the Center for Population Health Sciences at the Stanford University School of Medicine, in an original investigation published in JAMA Network Open.
The study found the highest rates of opioid-related deaths and more rapid increases in mortality were observed in eight states: Connecticut, Illinois, Indiana, Massachusetts, Maryland, Maine, New Hampshire and Ohio. Two states, Florida and Pennsylvania, had opioid-related mortality rates that were doubling every two years — and tripling in Washington, D.C.
Kiang and his co-authors, including Stanford Health Policy’s Sanjay Basu, MD, PhD,an assistant professor of medicine at Stanford Medicine, used data from the National Center for Health Statistics and corresponding population estimates from the U.S. Census. The other authors are Jarvis Chen, ScD, at the Harvard T.H. Chan School of Public Health, and Monica Alexander, PhD, in the Department of Sociology at the University of Toronto.
“It seems there has been a vast increase in synthetic opioid deaths in the eastern states and especially in the District of Columbia because illicit drugs are often tainted with fentanyl or other synthetic opioids,” Kiang said in an interview. “People aren’t aware their drugs are laced and more potent than they expected — putting them at higher risk of overdose.”
Synthetic opioid deaths now outnumber heroin deaths in these eastern states, which suggests fentanyl has spread to other illegal drugs and is no longer limited to heroin.
“The identification and characterization of opioid `hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the authors write.
The research suggests the opioid epidemic has evolved as three intertwined, but distinct waves, based on the types of opioids associated with mortality:
“The evolution has also seen a wider range of populations being affected, with the spread of the epidemic from rural to urban areas and considerable increases in opioid-related mortality observed in the black population,” they write.
The Centers for Disease Control and Prevention reports that African-Americans experienced the largest increase in opioid overdose deaths among any racial group from 2016 to 2017, with a 26 percent surge.
“The identification and characterization of opioid ‘hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the researchers write.
States are trying to combat the epidemic by enacting policies, such as restricting the supply of prescription drugs and expanding treatment and access to the overdose-reversing drug naloxone.
“Treating opioid use as a disorder should be our top priority to curb the problem,” said Kiang. “Similarly, we have the ability that counteract the effects of an overdose — these life-saving drugs should be easily accessible and widely available.”
The Effects of U.S. School Shootings on Children’s Antidepressant Use
More than 220,000 American students have experienced a school shooting since the 1998 Columbine High massacre. School shootings are vastly more common in the U.S. than in any other developed country, and are becoming more frequent and deadly in recent years. While these events receive widespread media coverage and incite public debates, there is little empirical research quantifying their population-level mental health impacts. We combined data on 44 school shootings between January 2008 and April 2013 with data on antidepressant prescriptions filled at retail pharmacies between January 2006 and March 2015. We compared the number of antidepressants prescribed to children under age 20 by providers located in close proximity of a school that experienced a shooting (shooting-exposed area) to those prescribed to children by providers located slightly further away (reference group), both in the two years before and the two years after a shooting. The average number of monthly antidepressant prescriptions written to children was significantly higher in the shooting-exposed areas relative to the reference groups in the two years after a fatal shooting versus the two years before. The effect persisted when extending the post-shooting observation window to three years and was similar when using an alternative reference group of providers located in close proximity to observationally similar schools without a shooting. We found no significant effects on children’s antidepressant prescriptions following non-fatal shootings or on adult antidepressant use. Our results suggest that local exposure to fatal school shootings increases antidepressant use among children under 20 years old, a previously unmeasured cost of these events.
Maya Rossin-Slater
Assistant Professor of Health Research and Policy, Stanford University
Faculty Fellow, SIEPER
Faculty Research Fellow, NBER
Research Affiliate, IZA
Maya Rossin-Slater is an Assistant Professor of Health Research and Policy at Stanford University School of Medicine. She is also a Faculty Fellow at the Stanford Institute for Economic Policy Research (SIEPR), a Faculty Research Fellow at the National Bureau of Economic Research (NBER) and a Research Affiliate at the Institute of Labor Economics (IZA). She received her Ph.D. in Economics from Columbia University in 2013, and was an Assistant Professor of Economics at the University of California, Santa Barbara from 2013 to 2017. Rossin-Slater’s research includes work in health, public, and labor economics. She focuses on issues in maternal and child well-being, family structure and behavior, and policies targeting disadvantaged populations in the United States and other developed countries.
CHP/PCOR Conference Room
123 Encina Commons
(Building located behind Encina Hall)